Senators Lamar Alexander (R-Tenn.) and Patty Murray (D-Wash.), the chairman and ranking member, respectively, of the Senate Health, Education, Labor, & Pensions (HELP) Committee, have held a series of four hearings showcasing what might be done in a bipartisan way to fix the law. Ideas mentioned frequently in the hearings included:

Appropriating funding for insurers' cost-sharing reduction (CSR) payments to help low-income enrollees with their out-of-pocket costs

Funding a "reinsurance" program to take insurers off the hook for high-cost patients

Giving states more flexibility in how they run their exchanges, including allowing for more variation in health plan design

During the bipartisan group’s public discussions, that last item appears to be a major sticking point, with Democrats insisting that patients remain covered for all the "essential health benefits" required under the ACA, and Republicans saying that Democrats must give a little in that area.

Whatever the problem, everything came to a halt late Tuesday afternoon. “Senator Murray and I had hoped to agree early this week on a limited, bipartisan plan to stabilize 2018 premiums in the individual health insurance market that we could take to Senate leaders by the end of the month,” Alexander said in a statement. “During the last month, we have worked hard and in good faith, but have not found the necessary consensus among Republicans and Democrats to put a bill in the Senate leaders’ hands that could be enacted.”

Murray issued her own statement. “I was very glad that Chairman Alexander kicked off this bipartisan process to tackle health care uncertainty and the higher premiums facing families if Congress doesn’t act,” she said. “We identified significant common ground and I made some tough concessions to move in Chairman Alexander’s direction when it comes to giving states more flexibility.”

“I am disappointed that Republican leaders have decided to freeze this bipartisan approach and are trying to jam through a partisan Trumpcare bill, but I am confident that we can reach a deal if we keep working together—and I am committed to getting that done,” she concluded.

Some analysts were disappointed by the development. ‘We had a glimmer of bipartisanship that was extinguished before it could grow,” Robert Field, PhD, JD, MPH, professor of health management and policy at Drexel University, in Philadelphia, said in an email. “It was nice while it lasted. Its failure is a loss for everyone. Whatever happens with Graham-Cassidy, insurance markets will be plunged back into uncertainty, and no one benefits from that.”

Others took it as a sign of the Republicans’ strategy to pass the Graham-Cassidy bill. “The Republicans decided it was [Graham-Cassidy] or nothing,” Joe Antos, PhD, scholar in healthcare and retirement policy at the American Enterprise Institute, a right-leaning think tank here, said in an email.

Now that the HELP effort is no more, Graham-Cassidy appears to be the only ballgame in town for Senate Republicans. That measure, introduced last Wednesday by senators Cassidy, Graham, Dean Heller (R-Nev.), and Ron Johnson (R-Wis.), would give money annually to states in the form of a block grant, which could be used “to help individuals pay for healthcare,” Cassidy’s office said in a press release posted on the senator’s website.

“This proposal removes the decisions from Washington and gives states significant latitude over how the dollars are used to best take care of the unique health care needs of the patients in each state,” the press release stated. “The grant dollars would replace the federal money currently being spent on Medicaid expansion, Obamacare tax credits, cost-sharing reduction (CSR) subsidies and the basic health plan dollars.”

The amount of money each state would receive is based on a complicated formula that starts with the amount of money each state receives from Medicaid expansion, ACA tax credits, CSR subsidies, and basic health plan funds. “By 2026, at base rate, every state will be receiving the same amount of money for each beneficiary in the 50-138% federal poverty level range,” according to an FAQ on Cassidy’s website. “This ensures that high-spending states and low-spending states come to parity at the end of the time frame.”

The measure would also repeal the ACA’s individual and employer mandates as well as its medical device tax, and would “strengthen the ability for states to waive Obamacare regulations,” the release continued. It also would “protect patients with pre-existing medical conditions,” the release noted, although critics have pointed out that it could in some cases allow for medical underwriting, with sicker patients being charged more for insurance.

But there are reasons that the Graham-Cassidy bill may not make it through, Adam Wilk, PhD, assistant professor of health policy and management at Emory University, in Atlanta, said in an email. For one thing, “It would mean a dramatic reorganization of health care financing and delivery, which could help to mobilize opposition from major stakeholders and grassroots groups.”

The Congressional Budget Office (CBO) has said it will not have time to do a full analysis of the bill — which would include its affect on the number of people covered — and instead will only analyze its effects on the federal budget. “If the Senate will not wait for a full CBO analysis of the bill, previous (highly unfavorable) CBO assessments of [the repeal bill passed by the House] and other Republican proposals … will be used as benchmarks, which could again mobilize opposition,” Wilk said.

Finally, “GOP senators have a very limited window during which to whip up the 50 votes they need,” and several Republican senators “[have signaled] they may be tough to persuade,” said Wilk.

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